IMO Report: Drug Errors Hurt 1.5 Million a Year

More than 1.5 million Americans are injured every year by drug errors in hospitals, nursing homes and doctor’s offices, a count that doesn’t estimate patients’ own medication mix-ups, says an Institute of Medicine (IOM) report.

The report, Preventing Medication Errors, calls for major steps to increase patient safety. Topping the list: All prescriptions should be written electronically by 2010.

Perhaps the most stunning finding of the report was that, on average, a hospitalized patient is subject to at least one medication error per day, despite efforts to improve care in the six years since the institute began focusing on medical mistakes of all kinds.

The new probe couldn’t determine how many victims of drug errors die. A conservative estimate in 1999 put the number of deaths at 7,000 a year. Also unknown is how many of the injuries are serious.

At least a quarter of all medication related injuries are preventable, the institute concludes. A preventable drug error can add more than $5,800 to the hospital bill of a single patient. Assuming hospitals commit 400,000 preventable drug errors each year, that’s $3.5 billion—not counting lost productivity and other costs—from hospitals alone, the report concludes.

Technology could prevent some errors, but there’s little incentive for hospitals and other care providers to invest in it, says University of Arizona pharmacy dean J. Lyle Bootman, who chaired the IOM probe. Bootman advises consumers to aggressively question doctors, nurses and pharmacists about their medications, whether they’re watching over a hospitalized loved one or figuring out their own pills at home.

How to battle drug errors is a troublesome issue because of the sheer volume and complexity of today’s medications. There are more than 10,000 prescription drugs and 300,000 over-the-counter products on the market. Many come with different usage and dosing instructions depending on the patient’s age, weight and other risk factors.

Plus, four of every five U.S. adults take at least one medication or dietary supplement every day, and almost a third take at least five. The more you use, the greater your risk of taking two that interact badly, especially if different doctors prescribed different drugs without knowing what you already take.

Also, doctors’ notoriously bad handwriting often confuses pharmacists and other health workers, who must give patients correct dosages of drugs that often have similar sounding names. Instructions given to consumers on how to take medicine are woefully inadequate, the report concludes. One part of the study found parents gave their children the wrong dose of over-the-counter fever medicines 47% of the time.

Among the report’s recommendations:

  • The government should take action to speed electronic prescribing.
  • Health workers must fully inform patients about medication use.
  • The nation should invest $100 million annually on research into how to prevent drug errors.
  • The Food and Drug Administration should improve the quality of drug information leaflets that accompany prescription drugs.
  • The government should establish national telephone hotlines to help patients unable to understand printed drug information because of illiteracy, language barriers or other problems.

For more information and to purchase a copy of the report, go to www.iom.edu/CMS/3809/ 22526/35939.aspx.


FAA Starts Performance Based Pay for Flight Controller Training

The Federal Aviation Administration (FAA) has started a new performance based initiative for flight controller training, shifting emphasis from tracking time to measurable results, according to FAA deputy administrator Bobby Sturgell.

“Under the old system, we’d pay—or rather, the taxpayer would pay—for a controller’s training as he worked his way up toward full certification,” Sturgell said at the International Aviation Training Symposium in Oklahoma City. “To be frank, we felt the whole process was too broad, too imprecise.”

It seemed training contractors were being paid for the hours they worked instead of the quality of the job they were actually doing.

We’re no longer interested in paying for mere time put in,” Sturgell said. “We want to pay for results—a finished product in the form of a controller trained to FAA standards, and performance based contracts will help us do just that.”

Sturgell also said commercial aviation training in the United States has reached its highest level of safety, in part because technological advances have reduced opportunity for human error. He pointed to the ability to simulate a routing center and terminal radar approach using high-fidelity systems.


Quality Professionals Needed to Review Colleges, Universities

The Higher Learning Commission’s Academic Quality Improvement Program (AQIP) is looking for quality experts from outside higher education to serve on teams reviewing accredited colleges and universities.

The Higher Learning Commission is an accreditation agency for colleges and universities. AQIP is a program that institutions can participate in to maintain accreditation. About 170 institutions are AQIP participants.

AQIP uses a feedback process similar to that of the Malcolm Baldrige National Quality Award to review the schools. It tries to include on each seven-person review team at least one person who can view higher education from a stakeholder (rather than provider) perspective.

Reviews begin each November and May. Team members review the schools’ portfolios and communicate by e-mail and telephone. Reviewers receive a small honorarium. Experienced reviewers sometimes make site visits to campuses.

To apply to be an AQIP reviewer, set up a free account at http://prapps.hlcommission.org/index.a4d?fuseaction=login.accountsetup and complete the online application. For more information on AQIP or the Higher Learning Commission, go to www.aqip.org, or www.ncahigherlearningcommission.org.


Center Developing RFID Tags for Hotels, Restaurants

Ngee Ann Polytechnic, a higher learning institute in Singapore, has opened a research and development center that specializes in customizing radio frequency identification (RFID) applications for the hospitality industry.

RFID systems, typically comprising embedded microchips and readers, can store and relay information like an item’s origin, time of purchase and expiration date. Initially used for tracking inventory, RFID technology has rapidly expanded beyond its early roots in warehouses and retail to other sectors.

The RFID Hospitality Management Systems center already has developed prototypes of tools for hotels and restaurants. Hotel devices include a self-service kiosk for guests to bypass the front desk and check themselves in and out with an RFID keycard, as well as a luggage management system that tracks baggage with radio tags.

Other prototypes the center is working on include RFID readers in elevators for hotel guests with special keycards to automatically select their room floors as they enter. The system also would detect unauthorized entry to exclusive or restricted areas.


Researchers Developing Self-Healing Semiconductor Chips

A group of researchers has begun a three-year project to create semiconductor chips that diagnose and heal themselves when they malfunction.

The Semiconductor Research Corporation (SRC), a university research consortium, the National Science Foundation and the University of Michigan are working to develop the defect tolerant chips. The chips would autonomously detect flaws and fix them with online collaboration software. The aim is to increase the life of products.

“On the chip, there can be system level checking going on and monitors so that when parts of it fail, the computation can be switched to other parts of the chip and maintain the functionality while not having to throw that chip out or having the system fail,” says William Joyner, of the SRC.

Currently, semiconductors use redundancy to find and diagnose problems, taking up quite a bit of chip area and performance power. The new technology can avoid this by more efficiently scanning for problems in a chip area, shifting the functions of that area to a different part of the chip, and fixing the problem before putting it back in use.

The research team will focus on analysis of the future landscape of hard silicon failures and their impact on nontrivial designs, such as microprocessors and their switch components. Although the project is funded for three years, the team expects to produce results periodically throughout the study.

For more information, go to www.extremetech.com/article2/0,1697,1994121,00.asp.

ASQ News

FOUNDATIONS IN QUALITY LAUNCHES CQE PROGRAM ASQ is adding a new program to its Foundations in Quality (FIQ) series. A preparation course for the new certified quality engineer exam will launch Sept. 22. The first date for the new exam is Dec. 2. The FIQ series features self-directed online preparation programs for ASQ certification exams and programs to learn quality basics. For more information, go to www.asq.org/self-directed-learning.

DEADLINES FOR CERTIFICATION EXAMS APPROACHING ASQ will administer several certification exams on Oct. 20 at the Quality Audit Conference in Reno, NV. The application deadline is Sept. 13. The application deadline for the Dec. 2 certification exams is Oct. 6. The Dec. 2 certified quality engineer (CQE) exam will be the first one based on the new CQE body of knowledge. For more information, go to www.asq.org/certification.

WEBSITE LAUNCHES INNOVATION NETWORK ASQ has added to its collection of online networks with one dedicated to innovation. The network features a discussion board and several articles. It was launched in response to ASQ’s 2005 Futures Study, which found innovation to be the second strongest influence on the future of quality, behind globalization. For more information and to register, go to: www.asq.org/communities/innovation-triz/index.html.

FREUND SCHOLARSHIP AWARDED Edrin Rouse has received ASQ’s Richard A. Freund International Scholarship for 2006. The $5,000 scholarship, named after a past ASQ president, supports a quality professional’s graduate study. Rouse, who has a master’s degree in industrial technology (quality systems) from Eastern Michigan University, has been accepted into the doctorate program in business administration at Northcentral University in Prescott, AZ, and plans to become a college professor. For more information, go to www.asq.org/about-asq/awards/honors/bio/rouse.html.

GOVERNMENT DIVISION HOLDS LEADERSHIP DIALOGUE EVENT The Government Division’s third annual Leadership Dialogue event will be Oct. 19 in Chevy Chase, MD. The Leadership Dialogue series features group discussions with peer level practitioners and experts. Presenters include Paul Davis, professor of leadership at the National Defense University; Janice Calnan, executive coach and author, and T. Irene Sanders, executive director of the Washington Center for Complexity and Public Policy. Cost is $250. For more information or to register, call Bruce Waltuck at 609-577-1584 or e-mail im4xlns@hotmail.com.

ASQ PARTNERS WITH UNITED ARAB EMIRATES ASQ has entered into an agreement with the Dubai Institute for Human Resource Development, a United Arab Emirates (UAE) government agency, to support the government’s efforts to promote quality and achieve excellence. Through this agreement, ASQ will offer its certification exams to the government and the private sector in the UAE. Sunil Thawani will continue to serve as certification proctor in the UAE. For more information, e-mail Mohammed Jassim Ibrahim, CEO of the Institute, at mohammed@dihrd.ae.


Quality Progress to Study Internal Service Quality

Quality Progress and Metrus Group, a research and consulting firm specializing in strategic performance measurement and organizational change, will survey ASQ members and customers to answer key questions related to the quality of internal customer service: How well are companies managing their internal support departments, and what kind of impact is it having on their bottom-line business results?

A decade ago, Metrus Group undertook one of the largest studies of internal service ever. It found dramatic differences in business performance between companies marked by high and low levels of internal service quality. At the time, relatively little attention was being given to the issue.

What has changed since the original study? Has a decade of process improvement, reengineering and outsourcing had an impact? And is internal service quality still a key driver of superior business performance?

William Schiemann, founder and president of Metrus Group, explains, “Our experience suggests that internal service remains a key differentiator between performance leaders and laggards. We will tap ASQ’s membership to learn if this is still the case, as well as what kinds of service improvements different functions have achieved since our earlier study.”

The e-mail survey will be conducted later this year with members and customers who have opted to receive e-mails from ASQ. Responses will be confidential. All who respond to the survey will receive a special executive summary of the survey results. A related article will run in Quality Progress early next year.

Short Runs

VOLUNTARY VOTING STANDARDS were reviewed during U.S. House of Representatives committee meetings in July. The National Institute of Standards and Technology serves as chair of the technical guidelines development committee under charter by the Help America Vote Act of 2002. This committee developed the 2005 voluntary voting system guidelines.

THE AUTOMOTIVE INDUSTRY ACTION GROUP (AIAG) and Odette International Ltd. have updated their joint Global Materials Management Operations Guidelines/Logistics Evaluation based on feedback from current users. Users include major automobile manufacturers and suppliers. For more information, go to www.aiag.org.

THE INSTITUTE FOR SUPPLY MANAGEMENT has issued a report on the importance of ethical practices and their influences on behavior within organizations. Social Responsibility and the Supply Management Profession is based on a survey designed to provide specific information on barriers and drivers to ethical behavior. For more information, go to www.ism.ws/about/mediaroom/newsreleasedetail.cfm?itemnumber=15116.

APICS, THE ASSN. FOR OPERATIONS MANAGEMENT, has entered into an agreement with Microsoft to enhance operations and communications for supply chain managers who use Microsoft Dynamics AX ERP software products. Under the agreement, the software will incorporate more than 3,500 operations management industry terms and definitions from the APICS Dictionary. For more information, go to www.apics.org.

THE SUPPLY-CHAIN COUNCIL has released version 8.0 of its industrywide supply chain operations reference (SCOR) model. The model is now available in both Microsoft Word and HTML and has an additional level one metric—return on working capital—in the assets attribute category. For more information, go to www.supply-chain.org.

THE INSTITUTE FOR TECHNOLOGY AND MANAGEMENT and the National Centre for Quality Management, both in India, are issuing a call for papers for their conference, Quality Management Practices for Organizational Excellence. The conference is scheduled for Aug. 16-17, 2007, in Mumbai, India. The deadline for papers is Feb. 1, 2007. For more information or to submit a paper, e-mail int.conf.qmp@itm.edu.

THE TURKISH SOCIETY FOR QUALITY will hold its 15th Quality Congress on Nov. 21-22, at the Lutfi Kirdar International Congress and Exhibition Centre in Istanbul. KalDer, Turkish Society for Quality is Turkey’s national partner of the European Foundation of Quality Management. For more information, go to www.kalderkongre.org.

THE CERTIFICATION COMMISSION for Health Care Information Technology (CCHIT) has given its first certifications to electronic health record vendors. Eighteen manufacturers, including Allscripts and General Electric Healthcare, received the certifications, which last three years. CCHIT is a nonprofit organization under contract to the Department of Health and Human Services. For more information, go to www.cchit.org.

ISA’S SP88 BATCH CONTROL standards development committee has formed a working group to update the first two standards in the ISO-88 series. The project will focus primarily on models and terminology but also will consider revisions to the state structures and guidelines for languages. For more information, go to www.isa.org.

The FACE of Quality

Name: Rodrigo Picado Sandino.

Residence: Turrialba, Costa Rica.

Education: Bachelor’s degree in industrial engineering from Universidad Internacional de las Américas in San Jose, Costa Rica.

Current job: Quality manager at Rawlings Costa Rica, which manufacturers all of the balls used by Major League Baseball in the United States. The Costa Rica factory also manufactures sports uniforms for high schools and colleges.

Introduction to quality: While a college undergrad, Picado had a professor, Omar Mora, who was a certified quality engineer. Mora explained to Picado that this title was recognized all over the world. “Once I heard this was a big opportunity, my interest in quality control began,” Picado says.

ASQ activities: senior member, certified quality engineer, quality improvement associate and Six Sigma Black Belt.

Personal: Single, 7-year-old daughter.

Favorite ways to relax: Playing with his daughter, listening to music and watching movies.

Quality quote: My mother has taught me quality since I was in kindergarten. It is amazing how something as simple as discipline can affect a person’s life and the quality of that life. I thank her for all the principles she has shared with me and instilled in me, and I will make sure all those quality values are transferred to my beloved daughter, because to me, that is the bottom line—quality of life.

ISO 9000

Tips Offered on Financial Benefits From ISO 9001

ISO 10014 is a new International Organization for Standardization (ISO) standard that offers guidelines on achieving financial benefits with ISO 9001 based quality management systems.

Paul Palmes, the ISO 10014 project secretary, says the standard was designed to identify growth opportunities and suggest tools to plan its implementation and measurement in financial terms.

ISO 10014, Quality Management—Guidelines for Realizing Financial and Economic Benefits, is available from ISO national member institutes (the American National Standards Institute in the United States) or from the ISO central secretariat at www.iso.ch/iso/en/cataloguedetailpage.CatalogueDetail?CSNUMBER=37263&ICS1=3&ICS2=120&ICS3=10 (case sensitive).

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